Alcoholism Treatment in the United States.

Almost 600,000 patients are treated for alcohol abuse and alcohol dependence in the United States each year. Yet no one treatment approach has been shown to be successful for all these patients. Innovative treatment modalities are being studied in an effort to make alcoholism treatment more effective and more economical.

I t is estimated that 9.6 percent of men and 3.2 percent of women in the United States will become alcohol dependent at some time in their lives (Grant 1992); many more men and wom en will exhibit drinking behavior that can be classified as alcohol abuse. Alcohol dependence is a chronic, primary psychi atric disorder characterized by a cluster of recognizable symptoms, including alcohol tolerance (i.e., needing more alcohol to become intoxicated); physical withdraw al; loss of control over drinking; and continued use of alcohol despite social, medical, family, or occupational problems (American Psychiatric Association [APA] 1994). Alcohol abuse is less severe than alcohol dependence. It is characterized by harmful consequences of drinking (e.g., failure to fulfill major social, family, or vocational obligations; recurrent alcohol use in physically dangerous situations; and repetitive legal problems) but without the development of alcohol tolerance, physical withdrawal, or compulsive alco hol use (APA 1994).
Both alcohol dependence and alcohol abuse are disorders that can and should be treated. According to a 1991 survey of alcoholism and other drug abuse treatment facilities and their clients, almost 575,000 clients were treated in 8,928 facilities in the United States (U.S. Department of Health and Human Services [USDHHS] 1993). Of these clients, 12 percent were admitted to inpatient programs, and 88 percent were treated as outpatients. Sixtyseven percent of the clients were white; 17 percent were AfricanAmerican; 12 percent were Hispanic; and 4 percent were Asian, Native American, and other ethnic groups. About 60 percent of the clients were in their twenties and thirties, 6 percent were ado lescents under 18, and 5 percent were over age 55. Twentyfive percent of the clients in treatment were women.
This overview describes current types and innovative components of alcoholism treatment and evidence of their effective ness. In addition, treatment needs of priori ty populations, 1 including older persons, women, and minority patients, are dis cussed. Current interest in patienttreatment matching as a means to increase the indi vidualization of services and, consequent ly, their effectiveness are considered. Finally, costeffectiveness and financing trends are addressed briefly. 1 For a definition of this term, see the section "Treatment for Priority Populations" on p. 257.

TREATMENT SETTINGS
Alcoholism treatment services are deliv ered in two general settings-inpatient and outpatient. Inpatient settings mostly consist of shortterm residential programs. They often are used for the early phases of treatment, particularly acute detoxification. Outpatient settings provide more longterm maintenance treatment, with group meet ings and individual counseling offered once or twice a week. Because of current concern over increasing health care costs, more emphasis now is being placed on outpatient care during all stages of recov ery. As a result, successful models of outpatient detoxification and intensive day treatment services have been developed.
These programs often are based on the disease model of alcoholism and on the 12step or Alcoholics Anonymous (AA) philosophy and practices. Abstinence from alcohol and other drugs (AOD's) is the primary treatment goal in these pro grams. Patients participate in frequent AA meetings and ideally are linked to an AA sponsor and a local AA chapter prior to discharge.
Inpatient settings, such as hospitals, provide intensive, highly structured treat ment, such as group therapy and alco holism education, for several hours daily. Issues covered in alcoholism education include health consequences, course of the disease, effects on the family, and other relevant topics. In addition to these group activities, clients work individually with a counselor to develop and imple ment a treatment plan that defines the treatment goals and to receive personal ized therapy for special problems or needs. An essential element of residential programs appears to be milieu treatment, that is, living with a large number of alcoholic patients who have had similar experiences and problems and who can offer insight and advice on the recovery process. Professional staff are available during the treatment's early stages to manage medical problems and to conduct a psychosocial evaluation to guide the treatment process. Toward the end of the hospitalization, treatment often involves the client's family, and the spouse or other family members may be asked to join the treatment process.
Walsh and colleagues (1991) recently investigated the effectiveness of inpatient alcoholism treatment. Alcoholics who were identified through employee assis tance programs were entered randomly into one of three treatment options: com pulsory residential treatment followed by AA attendance, compulsory community based AA attendance alone, or patient choice of treatment modality. The majori ty of patients in the third group chose either inpatient treatment (41 percent) or AA attendance (46 percent). All three groups showed substantial and fairly stable improvement in alcohol consumption and employment status over the 2year followup period; patients in inpatient programs, however, improved most on several measures of AOD use. Although these results suggest the effectiveness of residential treatment, they cannot be generalized, because no formal out patient treatment group was included in the study design.
A recent study by Finney and Moos (1991) also supports favorable longterm outcomes for alcoholics following resi dential treatment. Ten years after treat ment, married or cohabiting alcoholics were compared with a community sample matched on various health, demographic, and psychosocial characteristics. About 70 percent of the patients were abstinent or stable nonproblem drinkers during the last 5 years, and only 30 percent had relapsed to heavy drinking. Recovered Several studies highlight the role of patient compliance as a determinant of treatment outcome.
patients appeared equivalent to the com munity sample on measures of mental and physical health and occupational and family functioning, whereas relapsed patients generally fared worse than the community sample. These findings under score that many alcoholics are treated successfully and have a favorable long term treatment outcome. In recent years, inpatient treatment programs have undergone substantial changes. For example, length of stay in many programs has decreased dramatical ly as a result of increased emphasis on outpatient interventions and of cost pres sures from the insurance industry. Whether this affects treatment outcome has not been determined.
The client population also has changed in recent years and now includes more multiple substance abusers than before. Consequently, the emphasis in many programs has shifted from a focus on alcoholism only to a focus on combined AOD dependence.

Outpatient Treatment
The majority of alcoholic patients are treated on an outpatient basis. In 1991, 88 percent of the clients who sought treat ment for alcohol problems were treated in outpatient facilities (USDHHS 1993).
These facilities offered detoxification services (to about 3,200 clients), intensive outpatient care (to about 52,400 clients), and regular outpatient services (to about 641,400 clients).
Intensive Outpatient Care. Intensive outpatient programs were modeled after psychiatric day treatment programs, which emerged in the 1970's as alternatives to inpatient hospitalization. The intensive outpatient programs vary considerably in the amount of time that patients are treat ed, ranging from 8 hours per day, 7 days per week, to 3 hours per day, several days per week. Several wellcontrolled studies comparing inpatient and intensive outpa tient treatment have demonstrated compa rable longterm outcomes but significantly lower costs in the intensive outpatient setting. For example, Fink and colleagues (1985) reported improved rates of absti nence from alcohol and improved mood for patients treated in an intensive outpa tient program compared with those in an inpatient program. Comparable outcomes for the two groups were found for other measures of alcohol involvement, job stability, and interpersonal status (e.g., functioning in parental and spousal roles). Longabaugh and colleagues (1983) demonstrated that the treatment costs were much lower in intensive outpatient than in inpatient treatment.
Intensive outpatient treatment may offer two kinds of advantages. First, it has clinical advantages by allowing patients to practice relapse prevention and man agement skills while being in a highly structured treatment setting. Second, it has practical advantages, such as the ability to serve larger numbers of patients; increased scheduling flexibility (e.g., offering evening programs for employed patients); and an opportunity for the patients to maintain their established roles of employee, spouse, and/or parent while receiving intensive treatment.

Regular Outpatient
Care. Regular outpa tient alcoholism services are used as primary treatment or as extended aftercare following completion of an inpatient or intensive outpatient program. These types of outpatient services usually include weekly group therapy sessions, regular individual counseling sessions with an alcoholism counselor, participation in AA meetings, and family therapy when appro priate. The recommended treatment length generally is at least 1 year. The number of treatment sessions and the A l c o h o l i s m T r e a t m e n t i n t h e U n i t e d S t a t e s l e n g t h o f s t a y i n o u t p a t i e n t t r e a t m e n t a r e r e l a t e d p o s i t i v e l y t o l o n g t e r m i m p r o v e m e n t i n d r i n k i n g b e h a v i o r a n d o t h e r p s y c h o s o c i a l a r e a s ( P o l i c h e t a l . 1 9 8 0 ) . O u t p a t i e n t p r o g r a m s c a n s u p p o r t a n d e n h a n c e t h e i m p r o v e m e n t s a c h i e v e d i n i n p a t i e n t t r e a t m e n t . I n a s t u d y b y M c L a t c h i e a n d L o m p ( 1 9 8 8 ) , r e s i d e n t i a l p a t i e n t s w e r e a s s i g n e d r a n d o m l y t o g r o u p s w i t h n o , w i t h v o l u n t a r y , o r w i t h m a n d a t o r y o u t p a t i e n t a f t e r c a r e p a r t i c i p a t i o n f o r 1 2 w e e k s .  Physicians and other health care profes sionals deliver these interventions based on an assessment of the patient's alcohol use and alcoholrelated problems. During a brief, highly directive consultation, the professional informs the patient about the assessment results (e.g., elevated liver functions, absenteeism or lateness at work, or alcoholrelated arrests). The professional then offers clear strategies, such as goal setting and contracting, to reduce future drinking.

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Researchers have studied the effective ness of brief interventions in inpatient and outpatient health care settings. The find ings indicate that brief interventions reduce alcohol use and improve health status when compared with no interven tion (Wallace et al. 1988) and can be as effective as more extended treatment protocols (Chick et al. 1988). Bibliother apy, a type of brief intervention in which patients receive written materials on the harmful effects of alcohol and guidelines for reducing drinking, also has been found to reduce alcohol consumption and asso ciated problems (SanchezCraig et al. 1989). These interventions represent a potentially powerful and costeffective tool for early treatment of heavy drinkers identified in a variety of settings.

Pharmacotherapy
Three types of medications have received the most attention in research conducted on the longterm treatment of alcohol abuse/dependence: alcoholsensitizing drugs, anticraving drugs, and drugs that treat concurrent psychiatric disorders (Litten and Allen 1991; for more in formation, see the article by Anton, pp. 265-271).

AlcoholSensitizing Medications.
Such alcoholsensitizing medications as Antabuse ® are used to discourage patients from drinking during their rehabilitation program. When combined with alcohol, these drugs produce unpleasant effects, including facial flushing, nausea, vomiting, and increased blood pressure and heart rate. In a comprehensive wellcontrolled study of the effectiveness of Antabuse, Fuller and colleagues (1986) reported that the medication did not improve abstinence rates, the length of time to relapse, or psychosocial functioning more than did counseling alone. Patients on Antabuse who did not remain abstinent, however, drank less frequently than relapsed pa tients who did not receive the medication.
For almost all patients, Antabuse ap pears to act through a psychological mech anism rather than through the actual pharmacological interaction with alcohol; that is, the patients believe that they will become sick if alcohol is ingested and, therefore, do not drink (Allen and Litten 1992). Thus, patients who comply with the administration protocol typically achieve successful outcomes without actually experiencing the alcoholsensitizing reac tion. As a result, increased attention has been given to strategies to improve compli ance with the recommended medication regimen (Allen and Litten 1992).

Anticraving Medications.
Over the last several decades, research has shown that various neurochemicals (i.e., chemical messengers that modulate responses of neurons in the brain) play a role in the development of alcohol consumption, tolerance, and dependence. Studies now are focusing on neuroregulating medica tions to reduce craving for alcohol and alcohol's rewarding or intoxicating effects. One potential target is the opioid regula tory system. Two recent studies have re ported that naltrexone, which blocks opiate receptor sites in the brain, decreas es alcohol consumption and relapse in alcoholdependent men enrolled in outpa tient alcoholism treatment (O'Malley et al. 1992;Volpicelli et al. 1992; also see the article by Volpicelli et al.,.

Psychiatric Medications.
Many alcoholic patients report high levels of anxiety and depression when entering treatment. As a result, many studies have examined the effectiveness of a variety of antianxiety and antidepressant medications in both clinically anxious or depressed alcoholics and in patients who do not meet the clini cal definitions for these psychiatric disor ders (Liskow and Goodwin 1987;Litten and Allen 1991). The effectiveness of these drugs is still controversial. Many earlier studies did not find significant reductions in drinking as a consequence of pharmacological intervention (Dorus et al. 1989;Liskow and Goodwin 1987). In addition, safety concerns for some of these medications have been raised. These concerns include potential abuse of some psychiatric medications, dangers associat ed with mixing alcohol and medications, altered metabolism and elimination of some medications because of chronic alcohol use, and the risk of noncompliance with the therapy by patients with comor bid disorders (Zweben and Smith 1989).
More recently, researchers have stud ied medications that reduce the uptake of the neurochemical serotonin (e.g., fluoxe tine [Prozac ® ] or zimelidine) and nonben zodiazepine antianxiety drugs, such as buspirone. These drugs have known antidepressant properties and also de crease food and fluid consumption; either mechanism could decrease alcohol use. Naranjo and colleagues (1990) found a 20 to 25percent reduction in alcohol consumption in heavy drinkers who re ceived Prozac compared with patients who did not receive the medication.

Marital/Family Therapy
Reviews of marital and family therapy in alcoholism treatment have supported the importance of involving family members in the treatment process (IOM 1990). Spouse involvement improves both mari tal and alcohol use outcomes during the early posttreatment period (McCrady et al. 1986). Because of the difficulty of engaging spouses and other family mem bers in longterm therapy, brief marital/ couples therapy has been studied as a costeffective alternative to more tradi tional extended counseling. Zweben and colleagues (1988) found that a single session of advice counseling for couples improved drinking status and marital satisfaction to the same extent as eight sessions of couples therapy.
McCrady and colleagues (1991) stud ied the effectiveness of three levels of couples therapy: minimal therapy, therapy focusing on alcohol effects only, and alcohol/behavioral marital therapy (ABMT) that addressed alcoholrelated problems and general marital communication skills. Patients in all three groups had similar reductions in drinking 6 months after treatment. After 18 months, however, the number of abstinent days increased for patients who received ABMT and de creased for patients in the other two groups. ABMT patients also reported improved marital satisfaction and lower rates of marital separations than the other patients. Thus, improved general marital communication skills may be beneficial for both decreasing alcohol use and in creasing marital stability. These benefits may become more evident after longterm followup as the patients master and inte grate communication skills into their marital interactions.

Relapse Prevention
Relapse during the recovery process can be triggered by a variety of intrapersonal and interpersonal factors. Intrapersonal cues include stress, depression, and levels of alcohol craving and withdrawal. Inter personal factors include the negative life events and daily inconveniences that an individual experiences, as well as inter personal tension. Relapse prevention strategies have been developed to teach alcoholics how to cope effectively with potential relapse triggers. Monti and colleagues (1990) found that providing patients with training in both mood management (e.g., awareness and management of anger and negative moods) and communication skills (e.g., assertiveness, starting conversations, nonverbal communication, or receiving criticism) reduced alcohol use and im proved psychosocial adjustment. Yet not all patients respond to all treatments equally. Mood management training is more effective for patients who have less education and who have high levels of anxiety and craving (Rohsenow et al. 1991). The effectiveness of communica tion skills training, in contrast, is not influenced by these pretreatment patient characteristics. These findings suggest that both approaches to relapse prevention can be effective but that intrapersonal mood states may be more difficult to change in some patient groups.

TREATMENT FOR PRIORITY POPULATIONS
Priority populations are defined as groups currently underserved in treatment pro grams or as groups requiring special interventions because of unique treatment needs and/or the relative ineffectiveness of standard treatment programs (IOM 1990). These groups include older per sons, women, minorities, and adolescents (for information on the treatment needs of adolescents, see the article by Bukstein, pp. 296-301). Existing studies of treat ment outcome for priority populations often failed to apply rigorous methodolo gy in evaluating specialized services for these patient populations.

Older Persons
The rates of alcohol abuse and alcohol dependence are lower among older indi viduals than among other age groups. Patients over age 55 compose about 5 Treatment services that address specific needs and emphasize peer group participation can improve treatment outcomes for many patients.
percent of alcoholism treatment program admissions (USDHHS 1993). Although most older alcoholics report relatively stable heavy drinking throughout their life, about 40 percent of them experience a recent onset of alcohol problems (Hurt et al. 1988). This lateonset alcoholism is believed to result from agingspecific life stressors, such as retirement, physical illness, or death of a spouse.
Whether older patients need special ized treatment still is controversial. Most studies have found that older alcoholics do as well as younger alcoholics in mixedage programs (Atkinson et al. 1985). Other investigators have compared treatment outcome in agespecific and mixedage programs. Kofoed and col leagues (1987) found superior outcomes for older alcoholics who once a week attended a specialized group that used a slow pace, was less confrontational, and emphasized socialization and support. Patients in the specialized group remained in treatment longer, attended more group sessions, and were more than four times as likely to complete the program as were patients in mixedage groups. Relapse rates for patients in both groups were similar, but relapse was treated more successfully for patients in the specialized group. These findings suggest that age may be an important matching variable when optimizing treatment.

Women
Alcoholabusing or alcoholdependent women and men differ in a variety of biopsychosocial variables. For example, women typically begin drinking at a later age and seek treatment after a shorter duration of heavy drinking than men, suggesting a more rapid development of alcoholrelated problems (Blume 1986). Compared with men, alcoholabusing women also are at increased risk for depres sion, low selfesteem, alcoholrelated physi cal problems, marital discord or divorce, spouses with alcohol problems, a history of sexual abuse, and a pattern of drinking in response to life crises (IOM 1990).
Although many of these gender differ ences could be important in designing effective alcoholism treatment for wom en, little information is available on the relative effectiveness of traditional mixed gender programs and specialized treat ment services. Dahlgren and Willander (1989) conducted a wellcontrolled study comparing womenonly and traditional mixedgender treatment. In both pro grams, the women received comparable individual and group counseling, occupa tional therapy, and medical care, but services in the specialized program fo cused specifically on women's problems. Women in the specialized program re mained in treatment longer, had higher completion rates, and had improved psy chosocial and health outcomes compared with women in the mixedgender pro gram. These results indicate that treat ment outcome for women may be better in specialized programs.

Minorities
Some minority populations may be at increased risk for developing AOD de pendence, with more rapid and/or severe medical and psychosocial consequences. For example, Hispanic men in detoxifica tion were more severely dependent and showed greater cognitive impairment than did white or AfricanAmerican men (Castaneda and Galanter 1988). Such differences, as well as language and cultur al differences, suggest that providers of alcoholism treatment programs that serve minority clients should attempt to tailor their treatment curricula to meet the special needs of these clients. One strategy is to match therapists and patients on the basis of race or ethnicity (Nagy 1994). Wester meyer (1984) found that ethnically sensi tive treatment programs were more successful in attracting minority patients. Clearly, more research is needed to identi fy the specialized needs of minority alco holics and the extent to which treatment services targeted to minority clients can improve treatment outcome.

PATIENTTREATMENT MATCHING
Early reviews of alcoholism treatment generally concluded that although alco holism treatment was more beneficial than no treatment, there was little evi dence for a differential effectiveness of particular treatment approaches (e.g., Emrick 1975). This was attributable in part to the heterogeneity of patients and treatment approaches studied. The impor tance of patienttreatment matching re search (i.e., analysis of the interactions between patient characteristics and type of treatment intervention) is becoming increasingly apparent.
A study by Kadden and colleagues (1989) illustrates the rationale for patient treatment matching. The investigators examined the effectiveness of coping skills training and interactional group therapy designed to explore interpersonal relationships for patients with different levels of global psychopathology, 4 so ciopathy, 5 and cognitive impairment. The study found that patients with higher levels of psychopathology and sociopathy 4 Global psychopathology included factors such as mental health problems, current and lifetime anxiety and depression, and suicidal thoughts or actions. 5 Measures of sociopathy examined the client's level of conformity with societal norms (e.g., illegal activities). had better outcomes with coping skills training, whereas patients with lower levels of psychopathology and sociopathy or with cognitive impairments did better with interactional therapy.
If it were possible to predict which treatments would be most beneficial for specific patient subgroups, it also would be possible to optimize the use of treat ment resources, maximize treatment benefits for individual patients, and target treatment development for those patients not yet served effectively. Several strategies already are being used in clinical practice that attempt to match patients to existing treatment modal ities more effectively. For example, Hoff man and colleagues (1991) developed comprehensive guidelines for determining appropriate treatment placement using patient characteristics, such as psycho social functioning, alcohol dependence severity, medical and psychiatric status, acute intoxication and withdrawal symp toms, and prior treatment and relapse history. Treatment characteristics used for matching include setting, staffing patterns, types of therapies, and ancillary support systems. Such structured guidelines can be useful for health care providers to validate treatment placement decisions, for insur ance companies to monitor patient place ment, and for researchers to evaluate treatment (IOM 1990). These strategies, however, have not yet been validated by experimental studies.

FINANCING TRENDS IN ALCOHOLISM TREATMENT
Two research areas focus on the costs of alcoholism treatment. First, analyses of the costeffectiveness of treatment com pare costs and cost savings for treatment versus no treatment or among different treatment approaches. Second, studies of how alcoholism treatment should be financed compare public with private treatment settings and public with private insurance reimbursement systems.

CostEffectiveness
Research consistently has shown that alcoholism treatment reduces overall medical care costs of alcoholdependent clients. One recent study demonstrated that over a 14year followup period, health care costs for treated alcoholics were 24 percent lower than for untreated alcoholics (Holder and Blose 1992). Only a few studies, however, have analyzed the relative costeffectiveness of different types of treatment in different settings. Hayashida and colleagues (1989) com pared alcohol detoxification in inpatient and outpatient settings. The study found no longterm differences in the effectiveness of inpatient and outpatient detoxification but found that costs were approximately 10 times higher in the inpatient than in the outpatient setting. Outpatient detoxifica tion, therefore, may be a highly cost effective alternative to traditional inpatient detoxification for patients who do not require immediate hospitalization.
Holder and colleagues (1991) reviewed the costeffectiveness of interventions in 33 alcoholism treatment settings and treat ment modalities. Treatments were rated on effectiveness (based on drinking out comes in controlled studies) and cost (based on the recommendations of re searchers conducting controlled trials for the least expensive setting and the mini mum treatment duration). The study found that the more effective modalities consis tently were in the minimal to mediumlow cost range, whereas modalities with poor evidence of effectiveness generally were associated with higher costs. The investi gators stress, however, that these results cannot be generalized because patient treatment matching was not considered in their analysis. For example, although costly modalities may be rather ineffective for most patients, they may be necessary and costeffective for specific highneed patient populations.

Treatment Financing
Decisions regarding treatment setting are influenced strongly by pragmatic insur ance coverage issues in addition to patient choice and treatment matching. For exam ple, almost twice as many employees in insurance plans with more extensive inpatient coverage received inpatient care compared with employees whose plans had limited inpatient coverage (Holder and Blose 1991). Such findings under score the need for a reexamination of current reimbursement strategies that often provide better coverage for inpatient or hospitalbased services than for outpa tient or nonhospitalbased services.
A study of national trends in alcoholism treatment during the late 1970's and early 1980's (Yahr 1988) suggests that two separate alcoholism treatment systems are developing in this country-a private system for insured, financially stable pa tients and a public system for disadvan taged patients. According to the study, privately or corporately owned treatment facilities intended to generate profits typi cally offered medical detoxification and care in hospital settings and attracted subur ban patient populations (i.e., the most economically advantaged residential cate gory). Programs run by State or local gov ernments or by nonprofit agencies, in contrast, offered more outpatient detoxifi cation and care in outpatient or nonhospital facilities and served more innercity and rural patient populations. During the study period, treatment capacities increased in the forprofit facilities but decreased slightly in nonprofit and State or local government programs. It will be important in future research to examine factors that may im pact on these patterns, including the overall cost and effectiveness of different treatment components, the relative cost of treatment delivery by public and privatesector units, and the correspondence between insurance coverage and use patterns of alcoholism treatment programs.

CONCLUSIONS
The treatment of alcohol abuse and alcohol dependence has benefited from a variety of scientific and clinical advancements in the last decade. There is growing evidence for the effectiveness of outpatient settings for the delivery of treatment services for alcoholics in all stages of recovery. New focused treatment interventions have been identified that are effective and that can be offered alone or as part of more compre hensive treatment programs. For example, pharmacotherapy and marital skills train ing show promise for decreasing alcohol use and relapse risk.
Research on alcoholdependent priori ty populations continues to highlight the unique problems and treatment needs of older persons, women, and minorities. Several studies provide encouraging evidence that treatment services address ing specific needs and emphasizing peer group participation can improve treatment outcomes for many patients. These find ings lend further support to the impor tance of patienttreatment matching. An understanding of the interactions between specific patient, counselor, and treatment characteristics will yield the most suc cessful longterm outcomes for all alco holics. This information also will be critical in developing costeffective fi nancing and utilization management of alcoholism treatment in this country. ■